Gastroenterology Coding Alert

Question: Our payer requested documentation of our colonoscopy claim and we submitted all of the records. The payer denied the claim stating that our documentation was not sufficient to support the diagnostic colonoscopy and specifically said that we did not document the depth of penetration. Are we supposed to document the exact depth in every note? Must we note it in centimeters, inches, etc.?

California Subscriber

Answer: According to the Part B MAC in California, (Noridian Medicare), the colonoscopy report must describe “the maximum depth of penetration, a description of any abnormal findings, and any procedures performed as the result of such findings (e.g., biopsy).”

In addition, you must clearly and legibly document the medical need for the colonoscopy, as well as the test results and impact on treatment.

Therefore, speak with your gastroenterologist about the need to document the maximum depth that he advances the colonoscope during a diagnostic procedure. However, you don’t need to note how many centimeters the colonoscope advances. Instead, you’ll mention which structures the colonoscope reached, such as “the colonoscope passed the splenic flexure” or that it “reached the cecum.” A colonoscopy is considered complete if the cecum or an ileal-colonic anastomosis is reached, and if not complete, then either a 53 or 52 modifier must be applied. The guidelines are clear within the CPT^® language itself.